Family physicians are uniquely positioned to influence breastfeeding outcomes because they care for women and children from preconception counseling through well-child care and beyond. As Drs. Keister, Roberts, and Werner describe in their article in this issue of American Family Physician,¹ there is a sizeable evidence base that supports the multiple strategies for promoting, protecting, and supporting breastfeeding. Family physicians should ensure that all families receive structured prenatal breastfeeding education and have access to breastfeeding support from knowledgeable peers and professionals.

In addition to providing appropriate management of breastfeeding challenges, family physicians can advocate that the hospitals and birthing centers where they and their patients deliver participate in the Baby-Friendly Hospital Initiative (BFHI). Jointly administered by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), the BFHI seeks to foster the establishment of policies and practices that optimize breastfeeding in birthing facilities. Since its inception in 1991, more than 20,000 hospitals and birth centers worldwide have received the Baby-Friendly designation.² This designation is made after an on-site assessment verifies implementation of the WHO/UNICEF Ten Steps to Successful Breastfeeding (Table 1).³ In addition, Baby-Friendly facilities must comply with the International Code of Marketing of Breast-Milk Substitutes.⁴

In the United States, the BFHI is overseen by the nonprofit organization, Baby-Friendly USA. Baby-Friendly USA has designated 63 U.S. institutions as Baby-Friendly, and is working with an additional 70 that have declared their intention to seek this designation.⁵ Baby-Friendly USA provides interested institutions with guidance and technical assistance in moving toward certification. As Keister and colleagues note, systematic practice of the Ten Steps to Successful Breastfeeding has been documented to increase breastfeeding initiation and duration. The largest randomized trial of the BFHI (and one of the largest studies on breastfeeding ever conducted), the Promotion of Breastfeeding Intervention Trial, was published in 2001. This cluster randomized study involved 34 maternity hospitals and more than 17,000 mother-infant pairs in the Republic of Belarus. Infants who were born in hospitals that implemented the Ten Steps to Successful Breastfeeding were significantly more likely to breastfeed exclusively at three months (43.3 versus 6.4 percent, respectively; P < .001) and six months (7.9 versus 0.6 percent, respectively; P = .01) than infants born in hospitals that did not implement the Ten Steps.⁶

Another large randomized trial investigated the effect of instituting the Ten Steps to Successful Breastfeeding with and without a posthospital home visit from a health care professional. In this study, which was conducted in an urban center with high poverty, the breastfeeding initiation rate in both groups was 70 percent. Breastfeeding rates for those who received the home visit were 45 percent at three months and 25 percent at six months. Among those without the additional home visit, rates dropped to 10 percent at three months and 4 percent at six months, reminding us of the central importance of postdischarge follow-up and breastfeeding support.⁷ A recent randomized controlled trial in Singapore also found that postnatal support improves exclusive and total breastfeeding at six weeks, three months, and six months after delivery.⁸

Although there have been no randomized or controlled trials of the BFHI in the United States, the Boston Medical Center realized tremendous improvements in breastfeeding rates by instituting the Ten Steps to Successful Breastfeeding. Increases in breast-feeding initiation rates were seen especially among populations with traditionally low breastfeeding rates, such as black women born in the United States. After implementing the BFHI, the breastfeeding initiation rate in black women increased from 34 percent in 1995 to 74 percent in 1999.⁹

Research from the Centers for Disease Control and Prevention indicates an incremental effect of implementing the Ten Steps to Successful Breastfeeding, showing that for five selected interventions, the greater the number of interventions a new mother experiences, the greater the likelihood of breastfeeding success.¹⁰ Women who experienced none of the five steps measured were eight times more likely to stop breastfeeding by six weeks postpartum than women who reported experiencing all five steps. This study also found that the greatest risk factors for early weaning were late breastfeeding initiation and administration of formula. Early breastfeeding initiation is optimized by immediate skin-to-skin contact between mother and newborn, which Keister and colleagues identify as a crucial step for breastfeeding success.

All family physicians, including those who no longer provide maternity care, can be powerful advocates in their communities by encouraging hospitals and birthing centers to adopt the Ten Steps to Successful Breastfeeding and to participate in the BFHI. Armed with the knowledge of the positive health outcomes for the breastfed child and the breastfeeding mother, we can partner with obstetrician and pediatrician colleagues, maternity staff, hospital administrators, and our patients to raise awareness, build support, implement the Ten Steps, and improve breastfeeding success.